Left Ventricular Pseudoaneurysm: A Rare Cause of Chest Pain to Keep in Mind

Abstract

A man in his 80s presented with sharp central chest pain, diaphoresis, and dyspnea. He had a remote history of coronary artery bypass graft. Results of the physical examination were unremarkable, and initial vital signs were stable. Electrocardiogram was unrevealing. Troponins were elevated and flat. He was initiated on intravenous nitroglycerin, after which his symptoms resolved. However, his blood pressure decreased to a minimal systolic of 76 and diastolic of 50 mm Hg. Because of the resolution of his symptoms, immediate angiography was deferred, and the patient was admitted to the cardiac intensive care unit. Transthoracic echocardiography (TTE) showed a loculated pericardial fluid collection adjacent to the anterolateral left ventricular (LV) wall (Figure; Video 1, available online at http://www.mayoclinicproceedings.org). Contrast TTE showed extension of the contrast from the main LV cavity to the adjacent pericardial cavity, consistent with pseudoaneurysm (Figure; Video 2, available online at http://www.mayoclinicproceedings.org). Computed tomography angiography of the thoracic aorta confirmed LV myocardial rupture along the anterolateral wall with active extravasation of contrast (Supplemental Figure 1A-D, available online at http://www.mayoclinicproceedings.org). The patient’s hospital stay was complicated by acute kidney injury. In the setting of increased risk for dialysis, he opted for conservative management. He remained hemodynamically stable, and pericardiocentesis was not indicated. He was discharged 1 week later. Predismissal TTE redemonstrated the contained LV anterolateral wall rupture with systolic and end-diastolic flow through the myocardial defect (Supplemental Figure 2; Video 3, available online at http://www.mayoclinicproceedings.org). He did well after discharge and died 4 years later of metastatic bladder cancer. Left ventricular pseudoaneurysms develop when LV free-wall rupture is contained by adherent pericardium or scar tissue and is most commonly secondary to myocardial infarction.1Frances C. Romero A. Grady D. Left ventricular pseudoaneurysm.J Am Coll Cardiol. 1998; 32: 557-561https://doi.org/10.1016/s0735-1097(98)00290-3Crossref PubMed Scopus (0) Google Scholar Mortality rate is high both with surgically (23%) and medically (48%) managed patients. Our patient’s previous cardiac surgery was thought to provide him with protection against complete rupture owing to scar tissue formation along the pericardium. The authors have no competing interests. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxNTQxZDIwOGFjOGU1NzExNTdlMjNhZjAyYmQzOWFjZiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcyMjg1NzkzfQ.bVK6mgeslM0bvj2ghgDzATVaMK2nN-hvkaaOINrhzerjUTY0BhHMM0RiEzxLzEbBfhrwaelJakGbXXQRNll3c1A4XIQPAMOuOb2WwBwZngrk3sZqt9PQ4-QR1521dLqyo87FedzewHEVHQp1u1-hU63njZ80S64gIww7AGwvm1GYVyG_PUqN2dsULzDkhx0u4N5mSlj1ic-GJziWbDQxyp_vNNXowt-C79lK4_irrwGt4gwiXrVTBjmVW7EKxw5UnOPiqxuUal_anvunu52uzNW3lrhjfMSIvZiK_HwBXn1MpYIpEXuY1maXiO04cZRMuJsbkyi_csiLCsenlZMhWQ Download .mp4 (0.63 MB) Help with .mp4 files Supplemental Video 1eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmNmU1ZDFjYzFjN2ZjM2EwMWM5NDQwZTRiMmVjZTQwMyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcyMjg1NzkzfQ.Llq0S-_MHJRqyeGeS8Jl1MGMOD3jHXaMnSq2_kq2VhClHCQx7UQu2w1bavnJDzW-urKRKWcnlXxIP6c8ScTvUdDnqtsubhEVrzHW2JY3Z0uOy9wcg6B_njlmvDJ7DjHkNV_Wg1UShZnAe4D0BMcCn1xyOhNhnmdAmi6V4c4-scHYs1f39hzgdjf9w5F7dKcuSbIKlkrjtEY_qTeY2cR1xdts7_cPrryda-lMKtQI_u3_dJVyf6V98uOfmi83dlBu4IKiMAQTQqVhegEmZZMM2zW5oeMHuoJNa_Aucg2BGVfu0eSp_755fOFZplx8a3eJo6XSzsB117uy6si2bN1Rig Download .mp4 (1.19 MB) Help with .mp4 files Supplemental Video 2Supplemental Figure 2Predismissal transthoracic echocardiography demonstrating contained left ventricular anterolateral wall rupture with systolic flow through the myocardial defect (green arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0ZmEyNTIzYzc5NzdlNjg0NTUzNmI2MDcxMDM2ZTcxNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcyMjg1NzkzfQ.CLfwOf7c_tQ5ApbvTOhJiynY9JIChxJ0Ho88bUeccmwEp0wB49X9Fp6UwMS-Qib5WLnv2_nCIlFxES7Q4iG6BIz_EeZA793g_oji_oHVeYoGnFheqPblch42qUSdCpa-xMBwZcZ8c-gzQhvpS3I5zNtDduAhHgYApS4ZAabBZ_mf8tP7br0YwC9bwnbMsA_bSc96LWkKylKVzz_u0U1GrNP9PsBT48qp0Gx1eVFZH__eZ7YuQ8oU67aqRZrGIWmPiVzth5eA72Hj4DjTmNP5QgIm_xzs2b015kbpEQSmn5UIU2iD4DPfCHR1S9woNUB6-DHnncT-Dl6Z2dLsB5WWeA Download .mp4 (0.57 MB) Help with .mp4 files Supplemental Video 3